Medicaid-Financed Institutional Services: Characteristics of Nursing Home and ICF/IID Residents and Their Patterns of Care.
B. Characteristics of Enrollees' Intermediate Care Facility for People with Intellectual Disabilities Spells

Few Medicaid enrollees used ICF/IID services. Of the nearly 12 million enrollees who were either elderly or eligible on the basis of disability between July 1, 2006, and December 31, 2007, only 93,761 had been in an ICF/IID, and only 9 percent (8,430) of those individuals -- representing less than one-tenth of 1 percent of all elderly or disabled enrollees -- had new spells of care. Thus, turnover in ICFs/IID was significantly lower than the turnover rate reported for enrollees in nursing homes (Chapter II). The number of enrollees residing in ICFs/IID was also relatively low compared to the number of enrollees with ID/DD who received HCBS waiver services in the community: in 2006, approximately 410,000 individuals were enrolled in waivers for individuals with ID/DD (MR/DD waivers) in the states analyzed here (Ng and Harrington 2009).

Differences across states in the number of spells or new spells were likely due in part to different state policies with respect to ICFs/IID. For example, Oregon and Vermont, which have been leaders in promoting community-based care for the ID/DD population, each had only a single ICF/IID in 2007 and correspondingly low numbers of ICF/IID spells (zero, in the case of Oregon).22 As mentioned above with respect to nursing home users, a disproportionate number of new ICF/IID spells were concentrated in a handful of large states, with California, Texas, New York, and Illinois together accounting for 45 percent of all new spells. Although the percentage of ICF/IID spells that were new was substantially higher in some states--including Alaska, Montana, South Dakota, Rhode Island, and Colorado--the actual numbers of new spells in these states were low, together accounting for only one percent of all new spells.23

TABLE III.1. Medicaid FFS ICF/IID Use Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007

Total Number of Aged and Disabled Enrollees

Number of Enrollees with ICF/IDD Spells

Number of Enrollees with New ICF/IID Spells

Percentage of Enrollees with New ICF/IID Spells

Percentage of ICF/IID Enrollees with New ICF/IID Spells

All States

11,922,095

93,761

8,430

0.1

9.0

Alabama

215,562

253

32

0.0

12.6

Alaska

22,542

b

b

b

b

Arkansas

147,070

1,780

283

0.2

15.9

California

1,848,937

8,864

1,123

0.1

12.7

Colorado

115,524

150

30

0.0

20.0

Connecticut

113,746

1,261

115

0.1

9.1

Delaware

24,219

147

b

b

b

District of Columbia

43,901

695

89

0.2

12.8

Florida

661,152

3,060

135

0.0

4.4

Georgiaa

315,975

1,190

165

0.1

13.9

Hawaii

44,956

84

b

b

b

Idaho

44,065

617

93

0.2

15.1

Illinois

467,613

9,477

651

0.1

6.9

Iowa

101,732

2,332

167

0.2

7.2

Kansas

85,305

644

37

0.0

5.7

Kentucky

249,333

717

71

0.0

9.9

Louisiana

239,281

5,584

497

0.2

8.9

Maryland

168,074

342

19

0.0

5.6

Massachusetts

379,285

1,031

54

0.0

5.2

Michigan

413,303

143

20

0.0

14.0

Mississippi

185,700

2,921

336

0.2

11.5

Missouri

266,561

1,006

63

0.0

6.3

Montana

26,767

66

19

0.1

28.8

Nebraska

55,381

632

76

0.1

12.0

Nevada

45,739

144

22

0.0

15.3

New Jersey

288,719

3,074

177

0.1

5.8

New Mexico

77,024

274

34

0.0

12.4

New York

1,097,394

8,548

756

0.1

8.8

North Carolina

426,342

4,204

213

0.0

5.1

North Dakota

17,766

582

49

0.3

8.4

Ohio

471,689

7,793

617

0.1

7.9

Oklahoma

152,507

1,845

208

0.1

11.3

Oregon

107,585

0

0

0.0

0.0

Pennsylvania

685,973

4,077

193

0.0

4.7

Rhode Islanda

59,865

46

b

b

b

South Carolina

216,208

1,735

144

0.1

8.3

South Dakota

23,255

201

46

0.2

22.9

Tennesseea

391,227

1,280

36

0.0

2.8

Texas

803,650

12,696

1,225

0.2

9.6

Vermont

29,604

b

b

b

b

Virginia

216,853

1,917

193

0.1

10.1

Washington

232,549

59

b

b

b

West Virginia

122,980

569

92

0.1

16.2

Wisconsin

207,083

1,572

307

0.1

19.5

Wyoming

12,099

98

11

0.1

11.2

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTES: New spells are spells beginning on or after July 1, 2006.

Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.

Cell sizes of less than 11 are not displayed.

Although much emphasis has been placed on re-balancing services for the ID/DD population toward community settings in the wake of the Olmstead decision, concerns have been raised about the lack of institutional capacity in some states for individuals with complex needs (Western Interstate Commission for Higher Education 2009). For example, because no ICF/IID was located in Alaska during the study period, it placed its four enrollees requiring institutional services in three Idaho facilities.

2. Who Used ICF/IID Care?

The majority of enrollees with new ICF/IID spells were male and under 65 years old, with a substantial number having multiple spells of care during the study period. Unlike nursing homes, whose residents are more likely to be female and elderly, 60 percent of the 8,430 enrollees with ICF/IID spells were male, and 38 percent were between 21 and 44 years old (Table III.2). Significant percentages of enrollees residing in ICFs/IID were younger than 21 (29 percent) or between 45 and 64 years old (27 percent).

TABLE III.2. Characteristics of Aged or Disabled Enrollees with New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2007

Characteristic

Enrollees with One or More New ICF/IID Spells

Enrollees with Both New Nursing Home and NewICF/IID Spells

Number of Enrollees with New Spells in All States

8,430

994

Percentage female

40.1

47.4

Percentage non-Hispanic White

72.1

80.7

Age (Percentage of Subgroup)

Under age 21

29.0

4.4

21-44 years

38.4

29.5

45-64 years

26.5

49.0

65-74 years

3.8

10.0

75-84 years

1.5

5.4

85 years and older

0.4

1.7

Percentage with Multiple New Spells

14.6

100.0

Percentage with Spells in Both Nursing Homes and ICFs/IID

11.8

100.0

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTE: New spells are spells beginning on or after July 1, 2006.

Of all enrollees with new spells of ICF/IID care, 15 percent had more than one new spell within the 18-month period between July 2006 and December 2007, and 12 percent had spells in both ICFs/IID and nursing homes (discussed in greater detail below). Older women were much more prevalent among those who used both ICFs/IID and nursing homes: slightly less than half of all enrollees who received both types of institutional care were female, and 17 percent were over 65 years old, compared with only 6 percent for enrollees with only ICF/IID spells. It is possible that some ICF/IID residents were moved to nursing homes as they grew older and required more complex and continual medical care, but the vast majority of enrollees with stays in both types of institution (83 percent) were younger than 65.

TABLE III.3. MAS in First Month of First New Medicaid-Financed ICF/IID Spell Among Aged or Disabled Enrollees Eligible for Full Medicaid Benefits Any Time Between July 2006 and December 2007

States (by largest MAS group)

Total Number of Enrollees with new ICF/IID Spells

Percentage in MAS Group at Start of Spell

"Other"

Cash Assistance- Related

Medically Needy

Poverty- Related

Section 1115 Demonstration Waiver

Cash Assistance

Alaskac

e

e

e

e

e

e

Rhode Islandabc

e

e

e

e

e

e

Georgiaabc

165

21.8

78.2

0.0

0.0

0.0

New Mexicoc

34

e

e

e

e

e

Idahoc

93

e

71.0

e

e

e

Texasc

1,225

33.1

66.6

e

e

e

South Dakotac

46

e

63.0

e

e

e

Delawarec

e

e

e

e

e

e

Floridabc

135

35.6

61.5

e

e

e

Mississippic

336

38.4

61.3

e

e

e

North Carolinab

213

e

60.1

e

33.3

e

Michiganbc

20

e

e

e

e

e

District of Columbiab

89

e

e

e

e

e

Tennesseeabc

36

e

e

e

e

e

Montanab

19

e

e

e

e

e

Kansasbc

37

43.2

56.8

0.0

0.0

0.0

Wisconsinbc

307

39.7

56.7

e

e

e

Coloradoc

30

43.3

56.7

0.0

0.0

0.0

South Carolinac

144

27.1

56.3

0.0

16.7

0.0

Louisianabc

497

44.1

55.3

e

e

e

Arkansasbc

283

46.3

52.7

e

e

e

Californiab

1,123

4.5

51.4

41.7

2.4

0.0

North Dakotabd

49

0.0

51.0

49.0

0.0

0.0

Hawaiibd

e

e

e

e

e

e

All States

8,430

32.5

48.2

15.4

3.9

0.1

Massachusettsb

54

e

e

e

e

e

"Other"

Vermontbc

e

e

e

e

e

e

Washingtonbc

e

e

e

e

e

e

Wyomingc

11

e

e

e

e

e

Oklahomacd

208

81.3

13.5

0.0

5.3

0.0

Connecticutbd

115

73.0

24.3

2.6

0.0

0.0

Ohiod

617

69.5

25.0

0.0

5.5

0.0

Missourid

63

66.7

33.3

0.0

0.0

0.0

New Jerseybc

177

66.7

30.5

e

e

e

Iowabc

167

60.5

39.5

0.0

0.0

0.0

Virginiabcd

193

57.0

38.9

e

e

e

Nevadac

22

e

e

e

e

e

West Virginiabc

92

53.3

43.5

e

e

e

Pennsylvaniabc

193

52.3

40.4

e

e

e

Kentuckybc

71

52.1

43.7

e

e

e

Alabamac

32

50.0

46.9

e

e

e

Medically Needy

Nebraskab

76

e

e

57.9

e

e

New Yorkb

756

e

e

55.7

e

e

Marylandbc

19

e

e

e

e

e

Illinoisbd

651

25.7

22.4

40.4

11.5

0.0

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTE: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon. Methods used to determine which states utilized the 300% rule or had a medically needy program in 2007 are described in Appendix B.

Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.

State had a medically needy program in 2007.

State utilized the 300% rule in 2007.

Section 209(b) state. Because Section 209(b) states are required to allow persons receiving SSI to deduct incurred medical expenses from income to determine financial eligibility, some people in 209(b) states may be coded as medically needy even if the state had no medically needy program.

Cell sizes of less than 11 are not displayed.

3. How Did Enrollees Residing in ICFs/IID Become Eligible for Medicaid?

More enrollees using ICF/IID services qualified for Medicaid benefits through cash assistance-related criteria than through any other pathway, with the vast majority already enrolled in Medicaid prior to admission. Across all 45 states, nearly half of all enrollees in ICFs/IID qualified for full-benefits via the cash assistance pathway in 2007, followed by "other" criteria (33 percent) and medically needy programs (15 percent) (Table III.3).24 In roughly half of states analyzed (23 out of 45), the majority of ICF/IID residents with new spells qualified for Medicaid at the start of their spell due to their low-incomes -- that is, they qualified under cash assistance-related criteria. Moreover, in all states except Illinois cash assistance-related criteria represented either the most common or second most common pathway to Medicaid eligibility. Finally, cash assistance was the most common pathway to eligibility in the two states with the largest number of new spells: California and Texas. "Other" criteria were the most common pathway to eligibility in 15 states -- one-third of which are 209(b) states -- while medically needy programs were the most common pathway in four states. As with enrollees in nursing homes, poverty-related expansions were a common pathway to eligibility in Hawaii, Massachusetts, and North Carolina.

In contrast to enrollees in nursing homes, most enrollees living in an ICF/IID were enrolled in Medicaid prior to their first spell of institutional care, with only 11 percent not enrolled two months prior to admission (Table III.4). Among those qualifying for benefits two months prior to their ICF/IID stay, most qualified either via cash assistance (48 percent) or "other" (24 percent). Cash assistance was either the most common or second most common pathway to eligibility in all states except Illinois. Thus, recipients of Medicaid-financed ICF/IID services generally had low-incomes and were not spending down available assets as many nursing home residents do. As with enrollees in nursing homes, retroactive eligibility for Medicaid benefits at the time of admission to the ICF/IID likely accounts for some of the observed enrollment in Medicaid two months prior to admission.

TABLE III.4. MAS in the Two Months Preceding the First New Medicaid-Financed ICF/IID Spells of Aged or Disabled Enrollees Between July 2006 and December 2007

States(by largest MAS group)

Total Number of Enrollees with new Nursing Home Spells

Percentage in MAS Group at Start of Spell

Not Enrolled

"Other"

Cash Assistance- Related

Medically Needy

Poverty- Related

Section 1115 Demonstration Waiver

Cash Assistance

Alaskac

e

e

e

e

e

e

e

Rhode Islandabc

e

e

e

e

e

e

e

Vermontbc

e

e

e

e

e

e

e

Georgiaabc

165

e

15.8

75.2

e

e

e

South Carolinac

144

e

17.4

67.4

e

e

e

Michiganbc

20

e

e

e

e

e

e

Tennesseeabc

36

e

e

e

e

e

e

Marylandbc

19

e

e

e

e

e

e

Montanab

19

e

e

e

e

e

e

South Dakotac

46

e

e

63.0

e

e

e

District of Columbiab

89

e

e

62.9

e

e

e

Mississippic

336

e

21.4

61.9

e

e

e

New Mexicoc

34

e

e

61.8

e

e

e

Texasc

1,225

16.5

16.0

60.7

e

e

e

North Carolinab

213

e

0.0

60.1

e

25.4

e

Wisconsinbc

307

e

36.5

57.3

e

e

e

Louisianabc

497

e

19.9

56.5

e

e

e

Idahoc

93

20.4

e

55.9

e

e

e

Floridabc

135

e

25.2

53.3

e

e

e

Californiab

1,123

6.0

3.9

53.3

33.0

3.5

0.0

Alabamac

32

e

e

53.1

e

e

e

North Dakotabd

49

e

e

53.1

e

e

e

New Yorkb

756

e

e

51.9

e

e

e

Kansasbc

37

e

e

51.4

e

e

e

Delawarec

e

e

e

e

e

e

e

Hawaiibd

e

e

e

e

e

e

e

Arkansasbc

283

e

e

48.8

e

e

e

Pennsylvaniabc

193

e

e

48.2

e

e

e

Massachusettsb

54

e

e

48.1

e

e

e

All States

8,430

10.9

23.8

47.8

10.8

5.7

0.1

Coloradoc

30

e

e

46.7

e

e

e

Kentuckybc

71

e

e

45.1

e

e

e

West Virginiabc

92

e

e

43.5

e

e

e

Virginiabcd

193

e

e

43.0

e

e

e

Nevadac

22

e

e

e

e

e

e

"Other"

Oklahomacd

208

e

37.0

34.6

e

e

e

New Jerseybc

177

e

62.1

18.1

e

e

e

Ohiod

617

10.2

61.8

21.2

0.0

5.7

0.0

Wyomingc

e

e

e

e

e

e

e

Alaskac

167

e

64.1

e

0.0

0.0

0.0

Connecticutbd

115

e

61.7

e

e

e

e

Missourid

63

e

69.8

e

e

e

e

Washingtonbc

e

e

e

e

e

e

e

Medically Needy

Nebraskab

76

e

e

e

48.7

e

e

Illinoisbd

651

e

29.3

16.3

30.7

15.7

e

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Alaska, Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTES: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon. Methods used to determine which states utilized the 300% rule or had a medically needy program in 2007 are described in Appendix B.

Data for Georgia, Rhode Island, and Tennessee were included in the analysis even though total institutional care expenditures as reported by the MAX data and CMS Form 64 differed substantially (a variance across data sources of at least 33% in 2007), as there were no known data anomalies for these states believed to invalidate the MAX-based statistics.

State had a medically needy program in 2007.

State utilized the 300% rule in 2007.

Section 209(b) state. Because Section 209(b) states are required to allow persons receiving SSI to deduct incurred medical expenses from income to determine financial eligibility, some people in 209(b) states may be coded as medically needy even if the state had no medically needy program.

Cell sizes of less than 11 are not displayed.

ICF/IID residents who were enrolled in Medicaid prior to admission generally continued to qualify for benefits according to the same eligibility criteria following admission, with 87-93 percent of those who qualified via the "other," cash assistance, and medically needy pathways remaining in the same MAS group (Table III.5). As with nursing homes, the percentage remaining in the poverty-related group (46 percent) was lower, with most of those enrollees qualifying for benefits under "other" criteria following admission. Among those residents who were not enrolled in Medicaid two months prior to admission, approximately half qualified for Medicaid via the "other" pathway, with the remainder qualifying via the cash assistance (29 percent) and medically needy (19 percent) pathways.

TABLE III.5. Transitions in MAS at the Start of First New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2007

MAS Group Two Months Before Start of Spell

Number in MAS Group Two Months Before Start of Spell

Percentage in MAS Group at Start of Spell

"Other"

Cash Assistance- Related

Medically Needy

Poverty- Related

Section 1115 Demonstration Waiver

Not enrolled

915

49.2

29.0

18.5

a

a

"Other"

2,006

87.4

8.5

2.2

a

a

Cash assistance

4,028

7.8

87.0

4.5

a

a

Medically needy

912

a

5.6

92.9

a

a

Poverty-related

479

37.4

7.7

8.8

46.1

0.0

Section 1115 demonstration waiver

12

a

a

a

a

a

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTES: New spells are spells beginning on or after July 1, 2006. MAX data reported no new ICF/IID spells in Oregon.

Cell sizes of less than 11 are not displayed.

B. Characteristics of Enrollees' Intermediate Care Facility for People with Intellectual Disabilities Spells

1. How Long Did Enrollees Live in ICFs/IID?

Most enrollees living in ICFs/IID were long-term residents, with more than seven out of ten individuals with new spells staying for more than one year (Figure III.1). Some of these individuals might have required the level of services that can only be provided in an institutional setting. Others might have benefited from transitioning to the community, but their family members or guardians might have lacked information about community-based options or resources for facilitating a transition.

A second group of individuals, constituting 13 percent of all enrollees living in ICFs/IID, had very short stays of three months or less. In many cases, these short stays corresponded to ICF/IID closings. For example, Wisconsin -- which accounted for 23 percent (90 out of 390) of the very short spells that began in the second half of 2006 -- closed seven ICFs/IID between June 30, 2006, and June 30, 2007, four of which were larger facilities with 16 or more beds (Lakin et al. 2008; Lakin et al. 2007). California and New York, accounting for 20 percent of very short stays, also closed large facilities during this period.25

FIGURE III.1. Length of First New ICF/IID Spells Among Aged or Disabled Medicaid Enrollees with New Medicaid-Financed ICF/IID Spells Between July 2006 and December 2006

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTES: New spells in this figure are spells beginning between July 1, 2006, and December 31, 2006, inclusive; spells are censored at December 31, 2007. 2,908 enrollees had new ICF/IID spells beginning between July and December 2006. The median length of first new spells was 425 days for ICFs/IID.

2. Did Enrollees with ICF/IID Stays Also Have Nursing Home Stays?

Ideally, an individual with ID/DD who qualifies for Medicaid benefits and requires LTSS will be placed in the environment best suited to address his or her specific needs. Individuals with complex medical needs who require more or less continual access to nursing care might be best served in a nursing home.26 Historically, however, the lack of availability of certain services has sometimes resulted in individuals being placed in inappropriate settings. Early in the development of the ICF/IID program, for example, many persons with ID/DD who did not require a high level of nursing care were placed in nursing homes rather than facilities specifically geared to their needs (Lakin and Hall 1990).27

The closure of larger ICFs/IID in recent years, combined with the greater emphasis on HCBS for the ID/DD population, raises the question of where enrollees who had previously used ICF/IID services were placed: in other ICFs/IID, in nursing homes, or in the community?

A substantial minority of enrollees in ICFs/IID were admitted to multiple types of institutions, with 994 of the 8,430 (12 percent) with ICF/IID admissions also receiving nursing home care during the 18-month study period (Table III.6). These 994 individuals represented a tiny share (0.1 percent) of all enrollees in nursing homes. Thus, while it is unusual for a nursing home resident to require ICF/IID care -- which requires a diagnosis indicating a need for such care -- it is not uncommon for ICF/IID residents to require nursing home services at some point.

TABLE III.6. Use of Nursing Homes and ICFs/IID by Aged or Disabled Enrollees with Multiple Spells Between July 2006 and December 2007

Enrollees with Multiple Spells and the Order of Spells

Number or Percentage

Enrollees with both ICF/IID and nursing home spells

994

Percentage of all ICF/IID residents

11.8

Percentage of all nursing home residents

0.1

Enrollees with a first new ICF/IID spell followed by a nursing home spell

122

Percentage with no gap between spells

46.7

Percentage with a gap of 60 days or less between spells

84.4

Enrollees with a first new nursing home spell followed by an ICF/IID spell

872

Percentage with no gap between spells

59.4

Percentage with a gap of 60 days or less between spells

93.2

SOURCE: Mathematica analysis of 2006-2007 MAX data for 44 states and the District of Columbia with representative FFS nursing home and ICF/IID data (excludes data from Arizona, Indiana, Maine, Minnesota, New Hampshire, and Utah).NOTE: New spells are spells beginning on or after July 1, 2006. Spells are censored at December 31, 2007.

Most ICF/IID residents with nursing home spells lived in the nursing home prior to being admitted to the ICF/IID. Of the 994 enrollees in ICFs/IID who had multiple spells of institutional care, 872 moved from nursing homes to ICFs/IID, while 122 moved from ICFs/IID to nursing homes. Many of these enrollees appear to have been transferred directly: 59 percent of enrollees moving from a nursing home to an ICF/IID did so within one day, and similarly for 47 percent of enrollees moving from ICFs/IID to nursing homes. The gap between spells was less than 60 days for the vast majority of enrollees with spells of both types of institutional care. Given that ICF/IID residents who also have spells of nursing home care tend to be older (Table III.2), it is possible that ICF/IID-to-nursing home transitions occurred for enrollees with ID/DD who required more frequent or intensive nursing care as they grew older. Although it is unclear why a much larger number of enrollees transitioned in the opposite direction, some might have been admitted to nursing homes either while waiting for an ICF/IID bed to become available or to receive post-acute care within our observation period.

Several states -- including California, Florida, Illinois, Mississippi, Nebraska, Oklahoma, South Carolina, and Virginia -- had especially high percentages of nursing home spells following ICF/IID spells within two months.28 Among these states, there was no net change in the number of ICF/IID facilities from 2006 to 2007, although California and Illinois both closed larger facilities during this time. During the same period, Mississippi and South Carolina both closed smaller ICFs/IID, and Oklahoma actually added ICFs/IID. Consequently, it is possible that the closure of ICFs/IID in some states partially explained the use of nursing facilities by persons with ID/DD. It is also possible that downsizing among ICFs/IID that continued to operate further contributed to transitions, particularly of frail or elderly enrollees, from ICFs/IID to nursing homes.

3. Did Enrollees Receiving ICF/IID Care Also Use HCBS?

A large number of enrollees admitted to ICFs/IID used HCBS either before entering the ICF/IID or after returning to the community. More than 40 percent of all enrollees with ICF/IID spellsbeginning in 2007 used HCBS at some point, and 54 percent of those enrollees with shorter stays (beginning and ending in the first half of 2007) used HCBS in the previous year (Table III.7). Similarly, 53 percent of enrollees with shorter stays beginning and ending in the latter half of 2006 used HCBS at some point in 2007.29

TABLE III.7. HCBS Use Among Aged or Disabled Enrollees with New ICF/IID Spells Between July 2006 and December 2007

HCBS Use Relative to First New Spell of Institutional Care

Percentage

First new spells beginning in 2007 preceded by HCBS use in 2006

42.4

First new spells beginning in 2007 and ending on or before June 30, 2007, preceded by HCBS use in 2006

54.0

First new spells ending in 2006 followed by HCBS use in 2007

52.7

SOURCE: Mathematica analysis of 2006-2007 MAX data for 37 states and the District of Columbia with representative FFS nursing home and ICF/IID data and valid HCBS data (excludes data from Arizona, Indiana, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, Oregon, Pennsylvania, Rhode Island, Texas, and Utah).NOTES: New spells are spells beginning on or after July 1, 2006. HCBS includes 1915(c) waiver services, personal care services, residential care services, home health, adult day services, and private duty nursing services. Spells are censored at December 31, 2007. New spells beginning in 2007 preceded by HCBS use in 2006 refers to all spells beginning and ending at any time in 2007 (including spells censored as of December 31, 2007) that were associated with an enrollee who used HCBS at any time in 2006; the percentage is taken with respect to all first new spells beginning and ending (possibly censored) in 2007. The percentage of first new spells beginning in 2007 and ending on or before June 30, 2007, preceded by HCBS use in 2006 and the percentage of first new spells ending in 2006 followed by HCBS use in 2007 are defined analogously. State-level detail is provided in Appendix Table D.6.

Thus, despite the higher percentage of long-term stays in ICFs/IID, as compared with nursing homes (Figure II.1 and Figure III.1), substantially higher percentages of ICF/IID residents used HCBS before or following their stays (Table II.7 and Table III.7). It was common for a person with ID/DD in the study sample to use both HCBS and ICF/IID services, rather than only ICF/IID services. It is unknown whether this reflects: (1) changing levels of need for persons with ID/DD -- whereby the same individual uses either HCBS or ICF/IID services depending on his or her needs at a point in time; (2) a trial-and-error approach to identifying the most appropriate care setting for the individual; (3) ICF/IID closings; or (4) ICFs/IID -- specifically state institutions -- serving as crisis/emergency placement sites for individuals already being served either via HCBS or in another ICF/IID, or for people entering the Medicaid system in a crisis/emergency circumstance who are awaiting an alternative placement as soon as such a placement can be arranged.

The aggregate statistics on HCBS use before or after stays mask substantial variation across states. Considering shorter ICF/IID spells that began and ended during the first half of 2007,all had been preceded by HCBS use in 2006 in six states, whereas none of these spells was preceded by HCBS use in 12 other states.30 Similarly, 100 percent of shorter spells beginning and ending in the latter half of 2006 were followed by HCBS use in 2007 in five states, whereas no such spells were followed by HCBS use in another 12 states. Some HCBS use following ICF/IID stays was likely tied to the closure of a facility. For example, Iowa and Wisconsin both closed at least one-fifth of their ICFs/IID between 2006 and 2007. In these states, rates of 2007 HCBS use following shorter spells in the second half of 2006 were 100 percent, and 89 percent, respectively. However, other states that expanded their ICF/IID capacity during this period, such as Kansas and Kentucky, also had high rates of HCBS use following institutional stays.

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